F0725

F

Insufficient Nursing Staff Leading to Delayed Medications and Care

Georgetown, Indiana Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on multiple shifts, resulting in inadequate medication administration and assistance with activities of daily living for all residents. Staffing records and timecards for March 2026 showed repeated instances where individual Villas had only one nurse and no aide, or one nurse and one aide shared between two Villas, during both day and night shifts. On several nights, a single nurse and a single aide were responsible for residents in two separate free‑standing buildings, requiring them to leave one Villa without staff while they moved to the other. In at least one instance, a nurse scheduled for night shift did not clock in until early the following morning, further reducing coverage. Staff interviews confirmed that staffing was described as "awful" and that promised staffing levels of two aides per Villa or one nurse for two Villas with two aides were not consistently met.

Because of this understaffing, nurses and aides were unable to complete required care tasks in a timely manner. Staff reported that when only one aide and one nurse were available for two Villas, the nurse had to pass medications in both buildings and also assist with transfers requiring two staff, causing delays in medication administration and resident care. One staff member reported working alone in a Villa with nine residents, having to prepare meals, wash dishes, administer medications, complete treatments, provide resident care, and perform charting without an aide. Another staff member stated that she could not complete cleaning and laundry tasks on most days and tried to do them only on Sundays when there were no showers. Staff also reported that residents who required full body mechanical lifts often had to wait to get up or be put to bed because two staff were needed for transfers and the second staff member was frequently in another Villa.

Multiple residents with intact cognition reported not receiving medications and assistance in a timely manner due to lack of staff. One resident stated that insulin was received, but other medications were late, and another described medication timing as "hit and miss" when one nurse had to cover two Villas. Several residents reported consistently late medications and long waits for call lights to be answered, especially at night, with one resident stating they waited over an hour for a call light response and were frequently told by staff that there was not enough time. Residents who required mechanical lifts, including those with osteoarthritis, morbid obesity, diabetes, and lower extremity amputations, reported long waits to get out of bed, to use the bathroom, or to be put back to bed. One resident described waiting over 90 minutes for assistance to the bathroom, ultimately incontinent while waiting, and not receiving medications until late at night.

Medication administration records (MARs) documented repeated late administration of insulin for several residents with diabetes. One resident ordered to receive long‑acting insulin between 8:00 p.m. and 11:00 p.m. had doses given after midnight on multiple dates, including one dose administered at 4:46 a.m. Another resident ordered fast‑acting insulin before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m. had numerous doses given significantly late, including morning doses after 8:40 a.m. and midday doses after 12:40 p.m. A third resident with orders for morning long‑acting insulin and pre‑meal and bedtime short‑acting insulin had many doses documented as late, with morning doses given after 10:00 a.m., midday doses after 12:40 p.m. or later, afternoon doses after 5:45 p.m. or later, and bedtime doses given close to or after midnight. Residents also reported periods when no staff were present in their Villa for extended times in the evening, during which they could not obtain pain medication or diabetic medication on time. These findings collectively show that the facility did not ensure adequate nursing staff each day to meet residents’ needs for timely medication administration and assistance with daily living.

The facility’s own guideline document on Standard Supervision and Monitoring stated that staff assignments were to be based on resident needs and acuity, and that resident needs, including physical needs, would be met by providing as much hands‑on care as necessary. However, the documented staffing patterns, staff accounts, resident interviews, and MAR reviews demonstrate that the actual staffing levels did not meet these expectations. Residents experienced delays in transfers, toileting, and bedtimes, and insulin and other medications were repeatedly administered outside the ordered times, directly linked by staff and residents to the lack of sufficient nursing and aide coverage in the Villas.